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Radiology
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Request for Laboratory Investigation
Request for Laboratory Investigation
Patient Information
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Date of Request
Time
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Date Required (Results)
Health Insurance
No
Yes
Full Names
*
Full Names
First
First
Last
Last
Age
Gender
*
Male
Female
Patient File Number
Email
*
Phone Number
Brief Clinical Details (DDx)
Patient Weight
(If Patient is Obese)
Previous Result
(If Contrast is Required)
Allergies
Indicate NONE if no known allergies
Special Conditions
*
NONE
Pregnant
Diabetic
Hypertensive
Orthopaedic Implants
IUCD
Needs Mobility Aid
Investigations
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More input fields will appear below as you fill out the ones above
Pick Investigation
Heamatology
Serology
Infection Screen
RDT
Hormones
Chemistry
Urine
Stool
CSF
Sputum
Pleural Fluid
Specify Test
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Test
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
Pick Investigation
XRAY
Ultrasound
CT Scan
MRI
Cardiology
Obs/Gynae
Nuclear
Specify Anatomical Focus
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Doctor's Signature
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